Maternity Nursing: Postpartum Q 11
A nurse is assessing a client in the 4th stage of labor and notes that the fundus is firm but that bleeding is excessive. The initial nursing action would be which of the following?
A. Massage the fundus
B. Place the mother in Trendelenburg's position
C. Notify the physician
D. Record the findings
Correct Answer: C. Notify the physician
If the bleeding is excessive, the cause may be laceration of the cervix or birth canal. Perineal trauma is an extremely common and expected complication of vaginal birth. Lacerations can occur spontaneously or iatrogenically, as with an episiotomy, on the perineum, cervix, vagina, and vulva.
Option A: Massaging the fundus if it is firm will not assist in controlling the bleeding. Perineal massage has been shown to decrease the incidence of lacerations requiring suture, although the reduction was minor. Additional studies have shown a decrease in third- and fourth-degree lacerations when massage was performed during the second stage of labor, however, there is no consistently proven benefit.
Option B: Trendelenburg’s position is to be avoided because it may interfere with cardiac function. Delayed or immediate pushing after a woman reached ten centimeters of dilation showed no difference in the incidence of perineal lacerations. However, there was a higher incidence of delivery with intact perineum in women who delivered in the lateral position with delayed pushing compared to immediate pushing in the lithotomy position.
Option D: The most common complication of a perineal laceration is bleeding. Most bleeding can be quickly controlled with pressure and surgical repair. However, hematoma formation can lead to large amounts of blood loss in a very short time. Perineal support or a “hands-on” approach, can be protective of the perineum and decrease the severity of perineal lacerations at the time of delivery. However, studies are conflicting on the significant benefit to this measure.